ARCHETYPE ID | openEHR-EHR-CLUSTER.palpation_fetus.v0 |
Concept | Palpation of a fetus |
Description | Findings observed during the palpation of a single fetus in utero. |
Use | Use to record a narrative description and clinical interpretation of the findings observed during the palpation of a single fetus in utero, including during labour. Use this archetype to record the details about a single fetus; in pregnancies with multiple fetuses, details about each fetus will be recorded in a separate instance of this archetype. This archetype has been specifically designed to be used in the 'Examination detail' SLOT within the CLUSTER.exam-abdomen, CLUSTER.exam-uterus or OBSERVATION.exam archetypes, but can also be used within other ENTRY or CLUSTER archetypes, where clinically appropriate. Use to provide a framework in which CLUSTER archetypes can be nested in the 'Examination findings' SLOT to record additional structured physical examination findings - for example, specific abdominal or vaginal findings. The CLUSTER.exclusion_exam archetype can be nested within the 'Examination not done' SLOT to optionally record explicit details about the examination not being performed. Use to incorporate the narrative descriptions of clinical findings within existing or legacy clinical systems into an archetyped format, using the 'Clinical Description' data element. |
Misuse | Not to be used for recording the clinical history - use specific OBSERVATION and CLUSTER archetypes. For example OBSERVATION.story and CLUSTER.symptom_sign. |
Purpose | To record a narrative description and clinical interpretation of the findings observed during the palpation of a single fetus in utero, including during labour. |
References | Derived from: Palpation of fetus, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2007 Apr 19. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1024_2 (discontinued). Original archetype: Examination of the fetus, Rejected archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2018-04-11]. Available from: http://www.openehr.org/ckm/#showArchetype_1013.1.277 |
Copyright | © Northern Territory Department of Health (Australia), openEHR Foundation |
Authors | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2007-04-19 |
Other Details Language | Author name: Heather Leslie Organisation: Atomica Informatics Email: heather.leslie@atomicainformatics.com Date originally authored: 2007-04-19 |
OtherDetails Language Independent | {licence=This work is licensed under the Creative Commons Attribution-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by-sa/4.0/., custodian_organisation=openEHR Foundation, references=Derived from: Palpation of fetus, Draft archetype [Internet]. Australian Digital Health Agency (NEHTA), ADHA Clinical Knowledge Manager. Authored: 2007 Apr 19. Available at: http://dcm.nehta.org.au/ckm#showArchetype_1013.1.1024_2 (discontinued).
Original archetype: Examination of the fetus, Rejected archetype [Internet]. openEHR Foundation, openEHR Clinical Knowledge Manager [cited: 2018-04-11]. Available from: http://www.openehr.org/ckm/#showArchetype_1013.1.277, current_contact=Heather Leslie, Atomica Informatics, Australia |
Keywords | uterus, fetus, foetus |
Lifecycle | rejected |
UID | 99d05e31-11b9-4169-8d62-89a75c57af47 |
Language used | en |
Citeable Identifier | 1013.1.3191 |
Revision Number | 0.0.1 |
All | Archetype [runtimeNameConstraintForConceptName=null, archetypeConceptBinding=[SNOMED-CT: Stephen Chu, NEHTA, Australia Tim Garden, NT Department of Health, Australia Sam Heard, Ocean Health Systems, Australia Heather Leslie, Atomica Informatics, Australia (Editor) Ian McNicoll, freshEHR Clinical Informatics, United Kingdom Jeremy Oats, NT Health, Australia Jo Wright, NT Dept of Health, Australia, originalLanguage=en, translators= , subjectOfData=unconstrained, archetypeTranslationTree=null, topLevelToAshis={source=[], identities=[], contacts=[], ism_transition=[], provider=[], protocol=[], description=[], events=[], details=[], context=[], target=[], capabilities=[], items=[ResourceSimplifiedHierarchyItem [path=/items[at0001], code=at0001, itemType=ELEMENT, level=1, text=Fetus label, description=Identification of the fetus being examined., comment=For example: 'Baby 1'; 'Breech'; or 'Anterior'. This data element is relevant if there is more than one fetus being palpated at the same time., uncommonOntologyItems=null, occurencesFormal=1..1, occurencesText=Mandatory, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0002], code=at0002, itemType=ELEMENT, level=1, text=No abnormality detected, description=Statement that no abnormality was detected (NAD) on physical examination., comment=Record as True if no abnormality was detected on examination. Specific statements about the examination can be included in the 'Clinical Interpretation' data element. If 'No abnormality detected' is selected, then recording of other examination data elements becomes redundant, with the exception of only the 'Clinical interpretation' data element, which may be useful if a normal statement is desired for recording, for example 'Normal examination'., uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_BOOLEAN, bindings=null, values=Allowed values: {true}, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0003], code=at0003, itemType=ELEMENT, level=1, text=Clinical description, description=Narrative description of the overall findings observed during the physical examination., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0004], code=at0004, itemType=SLOT, level=1, text=Examination findings, description=Structured details about the physical examination findings., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.fetus_ openEHR-EHR-CLUSTER.fetus_ openEHR-EHR-CLUSTER.multimedia.v1 and specialisations or openEHR-EHR-CLUSTER.multimedia.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.exclusion_ openEHR-EHR-CLUSTER.fetus_ openEHR-EHR-CLUSTER.fetus_ openEHR-EHR-CLUSTER.multimedia.v1 and specialisations or openEHR-EHR-CLUSTER.multimedia.v0 and specialisations, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0006], code=at0006, itemType=ELEMENT, level=1, text=Clinical interpretation, description=Single word, phrase or brief description that represents the clinical meaning and significance of the physical examination findings., comment=Coding of the 'Clinical interpretation' with a terminology is preferred, where possible., uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0007], code=at0007, itemType=ELEMENT, level=1, text=Comment, description=Additional narrative about the physical examination findings, not captured in other fields., comment=null, uncommonOntologyItems=null, occurencesFormal=0..1, occurencesText=Optional, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=DV_TEXT, bindings=null, values=, extendedValues=null], ResourceSimplifiedHierarchyItem [path=/items[at0008], code=at0008, itemType=SLOT, level=1, text=Examination not done, description=Details to explicitly record that this examination was not performed., comment=null, uncommonOntologyItems=null, occurencesFormal=0..*, occurencesText=Optional, repeating, cardinalityFormal=null, cardinalityText=null, subCardinalityFormal=null, subCardinalityText=null, dataType=CLUSTER, bindings=null, values=Include: openEHR-EHR-CLUSTER.exclusion_ |